David Heller is on a path less traveled in the field of global health. He studies primary prevention of chronic, non-communicable diseases (NCDs) in low-resource settings.
NCDs – such as cardiovascular disease, hypertension or diabetes – are the leading cause of death worldwide, including in most low- and middle-income countries. Yet, communicable diseases – such as HIV, malaria and tuberculosis – have historically dominated the attention of global health researchers and funding streams, explained Heller, assistant professor of global health and internal medicine at Mount Sinai Hospital in New York City.
However, the two do not have to be mutually exclusive, as Heller discovered during his 2014-2015 GloCal Health Fellowship in Uganda.
He worked with the SEARCH (Sustainable East Africa Research in Community Health) study, a UCSF-led study aimed at eliminating HIV transmission through aggressive screening and universal treatment. “SEARCH’s goal is to identify all cases of HIV through screenings and start treatment at the earliest stage of the disease possible,” said Heller.
SEARCH also integrates this cutting-edge HIV research with the screening and treatment of NCDs. “Since SEARCH actively screens patients in Uganda and Kenya for HIV, the health ministers of both countries realized that we could simultaneously screen people for hypertension and diabetes, so testing for these chronic conditions was rolled into the study,” said Heller.
However, SEARCH’s capacity to screen and treat hypertension had not yet been fully evaluated. So Heller zeroed in on hypertension monitoring at a clinic in the Mbale region of Uganda for his GloCal research project, seeking to discover if the SEARCH HIV study was an effective approach to controlling hypertension.
But how did he get into this corner of global health in the first place?
Heller’s path to his GloCal project started when he was an undergraduate at Brown University. Attending Brown opened up a new world, more international and diverse than the suburban Connecticut neighborhood where he grew up.
“I was set on becoming a physician because of my interest in biomedical science, but when I learned about global disparities in income and health, I pivoted in a new direction. Like many interested in global health, I started in HIV,” said Heller. He traveled to Mali with an infectious disease training program for undergraduates and worked in an HIV research lab at Brown.
Meanwhile he sought experience in the world of public policy, completing an internship in the US Senate under Joe Biden, and spending two years post-graduation as an Emerson National Hunger fellow in Washington DC, where he fused direct service with policy. Although this experience was not global health focused, he learned that, “you can't do good policy work until you understand the situation on the ground. And doing work on the ground usually works best if you have a plan to scale it up into a larger intervention.”
Ultimately, he “wanted to understand the big picture of how policy and policy delivery influence the health of the public,” said Heller.
In medical school at UC San Francisco (UCSF), Heller honed his interests in HIV care, but also spent the first summer learning about health systems and health system strengthening with the World Health Organization in Geneva. He completed his MPH at John Hopkins, where he worked in Pakistan on a project studying hospitals’ capacity to treat traumatic injury, and then returned to Johns Hopkins for residency in internal medicine.
These experiences prompted Heller’s shift from HIV medicine in particular to health system delivery and primary care as a whole. “I wanted to understand why people are admitted to the hospital for complications of preventable diseases such as diabetes and hypertension – and I wanted to think about what we can do to think about primary prevention of chronic conditions to manage them better,” explained Heller.
To understand how to design and implement programs to prevent and treat these conditions – both in the United States and worldwide – Heller returned to UCSF for a primary care research fellowship. There he studied how academic researchers can work with policymakers to improve the delivery of primary care through the Medicaid program – and how statin medications for cholesterol can best be used to prevent heart disease in healthy but high-risk persons across the United States. But he knew his true passion was to build access to primary care – for multiple chronic conditions and beyond – in low- and middle-income countries. With these ideas in mind, Heller developed his GloCal Health Fellowship project through SEARCH with his mentor James Kahn, professor at the UCSF Institute for Health Policy Studies.
Heller recognizes Kahn for helping him learn how to think about research. “Jim taught me that research is not just about having a good idea and working hard. It’s about really thinking about how to ask and answer your research question as specifically and concretely as possible, especially in low-resource settings, said Heller.
In addition to Kahn, Heller is grateful for mentors and colleagues – Diane Havlir and Moses Kamya, co-PIs of SEARCH; Dalsone Kwarisiima and Florence Mwangwa, program director and clinical service coordinator, respectively, at SEARCH in Uganda; and Craig Cohen, professor of Obstetrics, Gynecology and Reproductive Sciences at UCSF – for supporting his development as a GloCal fellow and beyond.
“I’ve learned how to mentor from being mentored,” said Heller.
“My work with GloCal was really transformative for my opportunity to do a long-term academic career in this field. It was clear to the group that hired me [at Mount Sinai] that I had very concrete, specific expertise in long-term, immersive field research in the control of chronic diseases. And that became a jumping off point for really almost everything I've done since then,” said Heller.
Heller continues to collaborate with colleagues in Uganda and in 2016 he received a grant from the NIH Fogarty International Center to develop a nurse-led cardiovascular disease intervention in Ghana.
“The common theme of my work is examining how to provide integrative clinical care in sub-Saharan Africa – specifically looking at leveraging existing resources, such as HIV studies, to accomplish this,” said Heller.
Ultimately, he believes that, in global health, no matter your path, there is "no substitute for direct work in the communities you serve."